An inner affairs investigation into the loss of life of an inmate on the state’s largest jail reached “false and self-serving conclusions” as a part of an alleged cover-up of flaws within the coaching and actions of jail employees members, in response to a report by an knowledgeable in correctional psychological well being methods.

The report by Dr. Pablo Stewart on the suicide of a Halawa Correctional Facility inmate 5 years in the past alleges the investigation by Inside Affairs investigator Darren Tsuha contradicted the “clear video proof” within the case that confirmed a corrections officer didn’t make required cell checks on the inmate.

“Actually, it’s my opinion that the Inside Affairs Report ready by Tsuha, and authorized and accepted by Warden (Scott) Harrington, was an try to cowl up critical employees errors and omissions that any competent investigator would have recognized,” Stewart wrote.

Stewart’s scathing report on the loss of life of prisoner Joseph O’Malley was filed in Honolulu Circuit Courtroom in January in reference to a lawsuit within the case, and the state Legal professional Common’s Workplace admitted the state was accountable for O’Malley’s loss of life. Circuit Decide John Tonaki awarded O’Malley’s property $1.375 million within the case in March.

Stewart is an acknowledged knowledgeable on grownup and juvenile jail psychological well being methods who has reviewed amenities in California, Arizona, New Mexico and Illinois, and his report particulars an array of alarming flaws within the Hawaii system linked to the dealing with of O’Malley’s case.

The Division of Public Security declined on Wednesday to reply greater than a dozen particular questions on Stewart’s report, however mentioned in a written assertion that it “has sound coverage for the care and custody of inmates with psychological sickness.”

“The division routinely critiques and updates all insurance policies, and the coaching on such insurance policies, together with the inmate suicide prevention coverage which is in accord with nationwide requirements. Points recognized within the court docket proceedings and ultimate judgement both have been resolved or are at present being addressed,” in response to the assertion.

“The division has no additional remark to make,” it mentioned.

The Hawaii Correctional Programs Oversight Fee will take up the O’Malley case throughout its common assembly at 9 a.m. Thursday.

O’Malley was moved from suicide watch to “security watch” on July 11, 2017, and at last used a strip of clothes to hold himself in an commentary room within the medical unit of Halawa Correctional Facility on July 27, 2017. Greater than 25 minutes elapsed between the final verify of O’Malley in his cell, and the time he was discovered after hanging himself.

Stewart wrote that “maybe essentially the most alarming” side of Tsuha’s inner investigation into O’Malley’s loss of life was Tsuha reported a corrections officer had made the required checks of O’Malley in his cell each quarter-hour regardless of a video recording of the hallway exterior the cell that confirmed the officer walked by the cell with out trying inside.

Actually, O’Malley had used paper to cowl the window of his cell earlier than he killed himself, and the video confirmed the corrections officer walked down the hall “with out even turning his head within the path of the blocked window into the cell,” in response to Stewart’s report.

That corrections officer mentioned in his deposition within the case that he “didn’t even perceive that he was required to observe inmates on Security Watch,” in response to the report.

The inner affairs investigation additionally falsely asserted corrections officers and the nursing employees at Halawa had been correctly skilled within the suicide prevention coverage once they had not, Stewart wrote. One corrections officer reported in his deposition he didn’t recall present process any required suicide prevention refresher courses throughout his six years at Halawa.

“These false and self-serving conclusions are disturbing as a result of they exhibit that not solely are the suicide prevention practices at HCF woefully insufficient, however (Halawa) and DPS fail to train any sort of oversight, and actually exhibit an energetic unwillingness or incapacity to implement DPS’s personal insurance policies,” Stewart mentioned in his report.

Stewart’s report additionally notes Public Security’s then-staff psychiatrist Louise Lettich mentioned she didn’t even know the division’s suicide prevention coverage existed till she was getting ready for her deposition for the O’Malley lawsuit.

Lettich additionally mentioned in her deposition she was unaware jail employees have been confining inmates on suicide watch and “security watch” of their one-man cells for 22 or 23 hours per day.

That apply of isolating suicidal inmates was one other drawback, as a result of depriving these inmates of human contact together with visits, calls to household and recreation time can dramatically irritate psychological sicknesses, and will even be “profoundly damaging” to the psychological well being of inmates with no historical past of psychological sickness, Stewart wrote.

But Stewart’s report quotes the depositions of corrections officers who reported inmates on suicide watch have been held of their single cells for twenty-four hours per day aside from showers, and prisoners on security watch have been usually of their cells for 23 hours per day. The security watch inmates weren’t allowed out-of-cell recreation until “the physician gave them a rec memo.”

Stewart concluded suicidal inmates have been being held in isolation in violation of American Psychiatric Affiliation requirements and the division’s suicide prevention coverage, “apparently with out the information of their treating medical suppliers.”

Jail coverage at Halawa clearly requires the switch of inmates to Hawaii State Hospital for therapy if they’re so severely mentally ailing that they can’t be correctly cared for at Halawa, however Harrington mentioned in his deposition that he may solely recall one occasion when an inmate “probably” was transferred to HSH for that motive.

Lettich mentioned in her deposition she was unaware such transfers have been even a risk, however opined that O’Malley would have benefited from a extra therapeutic surroundings than Halawa may present, Stewart wrote.

One other alarming discovering by Stewart was that O’Malley and probably different inmates have been punished for acts of self-harm.

O’Malley was knowledgeable the day earlier than he dedicated suicide he can be positioned in solitary confinement after his discharge from security watch, a punishment Stewart mentioned was apparently as a result of a jail “Adjustment Committee” discovered O’Malley responsible of “self-mutilation” on July 20, 2017 when he had minimize his personal wrist with a disassembled fingernail clipper.

Harrington mentioned the coverage at Halawa was that inmates shouldn’t be sanctioned for injuring themselves, however the disposition in O’Malley’s case was “60 days lockdown,” in response to the Stewart’s report.

The Division of Public Security mentioned in its assertion to Civil Beat that Harrington, who was the warden at Halawa when O’Malley died, retired in late 2021. Tsuha, the interior affairs investigator who dealt with investigation into O’Malley’s loss of life, retired on the finish of 2020.